Membership Heeren XVII

Registration form membership Heeren XVII
Name*

PrefixFirst NameMiddle NameLast Name
Phone Number*
Please enter a valid phone number.Format: (+00) 0 00 00 00 00 .
Date of birth*

DayMonthYear
Date
Address room (Wageningen or surroundings)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address (home/parents)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Wur-mail*
Please enter your WUR e-mail address
Private email*
e.g. @gmail or @hotmail
Bank account number (IBAN)*
Ex: NL12 ABNA 1234 1234 12
Signature agreement preauthorized debit (for the payment of certain activities, contribution of articles we usepreauthorized debit)*

Clear
Date*

DayMonthYear
Date of signature
BATMBE
Registration number WUR*
Signature agreement processing personal data. The privacy guidelines can be found at: heeren17.nl/vereniging/privacyverklaring*

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Registration form membership Heeren XVII